AD-19 Indiana Department of Revenue
State Form 49514
Afﬁdavit for Reinstatement of Domestic Corporation
State of Indiana )
County of _______________ )
_________________________________________________ being duly sworn according to law, afﬁrms that he/she is the
___________________________________________ of _______________________________ a corporation organized
(ofﬁcial capacity) (corporation name)
under the laws of the State of Indiana, _____________________________ , with its principal ofﬁce located at address
____________________________________________________ , city ________________________ , state _________ ,
zip _______________ , and identiﬁed by Federal ID #______________________________ , and Indiana sales and/or
withholding tax TID # _______________________________ and that he/she makes this afﬁdavit for and on behalf of this
corporation. He/She states that the books and records of this corporation are kept at ____________________________ ,
in care of ___________________________________________ , and that this corporation is engaged in the business of
__________________________________________________________ . To the best of my belief and knowledge, all of
the said corporation’s Indiana taxable income received on and after May 1, 1933, has been included in Indiana income tax
returns ﬁled with the Indiana Department of Revenue and that all tax has been paid. The latest Indiana sales and/or
withholding tax return were ﬁled for the month/year _____/_____ , under the name of ___________________________ .
That this afﬁdavit is made for the sole purpose of inducing the Indiana Department of Revenue, to issue a notice as
provided by the applicable taxing acts to the effect that such corporation has paid all taxes due from it under the taxing
acts which will permit the Indiana Secretary of State to reinstate the corporation to active status.
State of Indiana )
County of _________________ )
Subscribed before me, a Notary Public in and for said county and state, this ______ day of _______________ , _______ .
Commission Expiration Date Signature
County of Residence Printed Name
Mail to: Indiana Department of Revenue, Tax Administration, P.O. Box 6197, Indianapolis, IN 46206.
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